A 51‐year‐old white woman was admitted with a 3‐day history of recurrent generalized abdominal cramping and bloating with 10–15 nonbloody watery diarrhea stools per day. She denied nausea, vomiting, fever, chills, or sweats. Her medical history was remarkable for a right hemicolectomy for diverticular disease and subsequent colostomy reversal 3 years ago. The last 3 months she complained of episodic constipation and crampy nonbloody diarrhea. She was treated with empiric oral ciprofloxacin after colonoscopy and barium enema 10 weeks prior to admission showed diverticulosis. The patient admitted cocaine and PCP use 1 week ago and use of marijuana as a sleep aid. Abdomen exam revealed moderate distention, generalized tenderness greatest in the right upper and lower quadrants, but no rebound or rigidity. Abdomen CT revealed pneumatosis intestinalis in a right upper quadrant section of the colon. Labs showed white blood cell count of 6400 with 14% bandemia and low serum bicarbonate of 22 mEq/L, and she was admitted for suspected bowel ischemia and placed on empiric piperacillin/tazobactam. Abdominal CT angiogram, however, revealed no abnormalities in the mesen‐teric vessels. A stool sample returned positive for Clostridium difficile, and a change to oral metronidazole rapidly resolved her pain and diarrhea.
Pneumatosis intestinalis (PI) is the uncommon radiologic finding of gas in the wall of the gastrointestinal tract. PI from intestinal ischemia is often a surgical emergency that represents one end of the spectrum of etiologies that includes multiple other nonsurgical conditions. Compromised mucosal integrity, intraluminal pressure, and gut bacteria are etiologic factors. C. difficile infections and PI were initially described in pediatric transplant patients and rarely seen in immunocompetent adults. C. difficile toxin damages the tight junctions of the intestinal epithelia, thus disrupting the mu‐cosal barrier. We hypothesize that this patient's cocaine use contributed to transient microvascular ischemia, further compromising colonic mucosal integrity and leading to pneumatosis intestinalis. In the absence of frank ischemia or bowel infarction, PI can be treated medically in many cases.
Pneumatosis intestinalis in this older adult was caused by a combination of cocaine use and Clostridia difficile toxin. Cocaine use should be suspected in patients presenting with possible bowel ischemia such as PI. Older adults may not “age out” of illicit drug use, which is projected to double by 2020 as the baby boomer generation ages. Clostridia difficile toxin should be included in the differential diagnosis of pneumatosis intesti‐nalis even if the patient is immunocompetent and the antibiotics exposure was remote.
L. Burke ‐ none; K. Nau ‐ West Virginia University Department of Family Medicine–Eastern Division, employment; Z. Phillips ‐ none
To cite this abstract:Nau K, Burke L, Phillips Z. Pneumatosis Intestinalis: A Curious Combination of a Drug and a Bug. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 349. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/pneumatosis-intestinalis-a-curious-combination-of-a-drug-and-a-bug/. Accessed April 6, 2020.